Nearly 25% of Americans die in intensive care units (ICUs), the largest proportion of whom are older persons with advanced illness. Most deaths in ICUs are expected and involve the removal of ventilator support, or palliative ventilator withdrawal (PVW). Prior work by the Principal Investigator (PI) found more than two-thirds of ICU patients undergoing PVW were over age 60. Moreover, there are unique management considerations when transitioning an older ICU patient to comfort care, including for the PVW process (e.g. choice and dose of drugs to alleviate distressing symptoms and approach to agitated delirium). While research conducted over the past 15 years has informed several aspects of palliative care in the ICU, relatively little of that work has focused on PVW. As such, PVW practices vary widely, and patient suffering is common; 30-59% of terminally extubated patients experience dyspnea. Thus, experts and national organizations have called for evidence to inform guidelines for PVW, an area of particular relevance to older patients. The over-riding objective of the proposed research is to generate the evidence-base to improve PVW in older ICU patients. The Specific Aims are: 1. To better understand the patient experience and providers? perspectives, 150 mechanically ventilated ICU patients over 60 years old will be recruited and prospectively followed in two Boston hospitals (180 beds) undergoing PVW. 2. To develop and refine a Comfort Measures Only Time out (CMOT) intervention consisting of a structured time out with check-list protocol for the ICU team (nurse, physician, respiratory therapist) to improve the process of PVW. 3. To pilot test the CMOT intervention in 4 ICUs (2 medical/2 surgical) among 40 PVW patients. Impact: By rigorously characterizing the experience of older ICU patients undergoing PVW, and developing and pilot testing a novel CMOT intervention, the proposed work will generate the much need evidence base to improve the care provided to this vulnerable population. Findings will directly inform the design of a larger RCT (R01) to fully evaluate the intervention. This work will establish the PI as an independent investigator with unique skills conducting palliative care intervention research among older adults in the ICU setting.